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  • 1. ajn@wolterskluwer.com AJN ▼ June 2013 ▼ Vol. 113, No. 6 67EVIDENCE FOR EXCELLENCEPromoting Healthy Sexual Behavior inAdolescentsWhat the research says.Adolescents who engage in early sexual rela-tions have a high risk of sexually transmittedinfections (STIs), pregnancy, and emotionalpain.1The Centers for Disease Control and Preven-tion estimates that youths account for more thanhalf of the 20 million new STIs that occur each yearin the United States.2In 2010, 367,678 infants wereborn to girls 15 to 19 years of age.3The individualand social costs of STIs and teen pregnancy indicatea need to help adolescents learn strategies for mak-ing better decisions about sex. Sex education, oneintervention used to provide guidance, has been thesource of heated debate for over a decade.4This de-bate primarily focuses on whether or not sex edu-cation influences adolescents to engage in early andrisky sexual behavior (such as having multiple part-ners or unprotected intercourse).The two most common sex education curriculain the United States are abstinence-only and compre-hensive sex education. Studies have compared andcontrasted the outcomes of both,4but few have exam-ined how peer groups and families influence adoles-cent decisions about sex.5Even fewer studies haveinvestigated the role of adolescent development onbehavioral outcomes.6This article will examine sev-eral studies exploring sex education programs andadolescent decision making within the context ofcognitive development. It will also offer recommen-dations for evidence-based interventions that may re-duce risky adolescent sexual behavior.STAGES OF COGNITIVE DEVELOPMENTTo better understand adolescent sexual behavior, abrief summary of cognitive development provides in-sight into how adolescents make decisions. Research-ers divide adolescence into three stages:• Early: 10 to 14 years6; 11 to 13 years7• Middle: 15 to 17 years6; 14 to 16 years7• Late: 18 to 21+ years6; 17 to 21 years7Cognitive skill is required to link consequencesto behavior. In early adolescence, thinking is predomi-nately concrete (only the here and now is relevant, forexample) and long-term consequences are not consid-ered. In middle adolescence, abstract thinking starts(although in times of stress, the middle adolescentoften reverts to concrete thinking) and consequencesof behavior begin to be considered. In late adoles-cence, abstract thinking begins to mature and con-sequences of behavior are considered.6, 7ADOLESCENT SEXUAL DECISION MAKING:A REVIEW OF THELITERATUREResearch often provides quantitative data addressingthe “who, what, when, and where” of adolescent sex-uality. But it’s equally important to understand the“why”—why do adolescents make certain sexual de-cisions? To better answer this question, Fantasia con-ducted a comprehensive literature review of adolescentdecision making, selecting for review 17 studies pub-lished in peer-reviewed journals from 1998 to 2009.8She found that adolescents who decided to pursue sex-ual relations fell into one or more of three categories.• They minimized the risks of sexual activity.• They had specific risk factors for engaging inunsafe sexual behavior.• They believed that sexual activity was “safe” inrelationships.By Deborah M. Wisnieski, PhD,APRN, and Marianne Matzo,PhD, APRN, FPCN, FAANPhoto©Camerique/ClassicStock/TheImageWorks.AJN0613.Matzo.EvidenceforExcellence.4th.indd 67 5/9/13 2:11 AM
  • 2. 68 AJN ▼ June 2013 ▼ Vol. 113, No. 6 ajnonline.comEVIDENCE FOR EXCELLENCEThe following is a review of some of the evidenceFantasia found to support these categories.Minimizing the risks of sexual activity. Kershawand colleagues studied a group of 411 urban femaleadolescents ages 14 to 19 who engaged in unprotectedsex with multiple partners.9Over half believed theirbehavior was only “slightly risky” or “not at all risky.”Chapin studied 180 black male and female adolescentsages 10 to 17; he found that while condom use wasinconsistent, the students exhibited “optimistic bias,”the misperception that they were less at risk than theirpeers of causing or experiencing pregnancy.10Theyalso overestimated the amount of sexual activity theirpeers engaged in, which is potentially risky becauseof adolescents’ desire to imitate peer behavior.Risk factors. In a study by Zwane and colleagues,female adolescents said they engaged in sexual activ-ity to be accepted by their peers and to avoid the labelof being “old fashioned.”11Sexual activity was alsoreported in another study as filling the adolescents’need to feel important and cared about.12Factors con-tributing to risky sexual behavior also include lackof close maternal supervision,13use of drugs and al-cohol, and sensation seeking.14Believing in the safety of relationships. Adoles-cents may believe they are in a safe relationship be-cause they experience a sense of familiarity with theirpartner.8In a large sample of more than 1,000 earlyand middle adolescents, 40% reported initiating sex-ual activity within one month of establishing a datingrelationship.15Reported condom use in dating rela-tionships was low; 47% used condoms with a casualpartner, while only 37% used them with a primarypartner.16Unfortunately, monogamy was also unusual;Lenoir and colleagues found that 42% of male ado-lescents reported sexual contact with someone out-side of the dating relationship.17Once an adolescent establishes a relationship ofmutual liking and trust, the use of condoms is oftenshort lived.18One study revealed that, on average,many adolescents stop using condoms after 21 daysinto the relationship.19Fear of rejection and anxietyabout discussing intimate sexual issues tends to leadadolescents to prioritize the maintenance of the rela-tionship over safety. The misperception of low healthrisk combined with the false sense of invulnerability(an aspect of early and middle adolescent develop-ment) can compound the risk of poor decision mak-ing.16Recognizing a partner’s motives and setting highexpectations within a relationship were two factorsfound to support consistent condom use among sexu-ally active 13-to-17-year-old girls.12THE INFLUENCE OF SEX EDUCATION ON SEXUAL ACTIVITYSex education can help adolescents make more in-formed decisions and is most effective among earlyadolescents, who have shown a documented decreasein risky sexual behavior after completing instruction.4In the United States, there are two types of sex edu-cation curricula: comprehensive and abstinence only.Comprehensivesex education includes messages aboutabstinence but also teaches methods of contraceptionand the use of condoms to avoid STIs.4Comprehen-sive sex education programs are designed to provideinformation about safe sexual practices to both sex-ually active adolescents and those who may need thisinformation in the future. Abstinence-only educationteaches that there are social and psychological advan-tages to remaining sexually abstinent. These programsare required to teach that abstinence from sexual ac-tivity until marriage is the “expected standard” andthat condoms are ineffective in protecting against STIsand pregnancy.4Because abstinence is the only accept-able option, other forms of contraception are not ad-dressed.Abstinence-only supporters often believe that pro-viding information about contraception and condomsencourages adolescents to engage in sexual activity—despite evidence to the contrary.20-22Governmentfunding for abstinence-only programs has decreasedsignificantly since the George W. Bush administration.However, despite the paucity of data indicating thatthis curriculum reduces teen pregnancy or rates ofsexually transmitted disease, the federal governmenthas continued to support it, allocating $50 million toabstinence-only education in both 2010 and 2011.23Abstinence-only vs. comprehensive sex educa-tion. The National Survey of Family Growth collecteddata from approximately 1,719 male and female het-erosexual adolescents (ages 15 to 19) to compare theeffectiveness of abstinence-only, comprehensive, andno formal sex education.4Adolescents from nonintactor low-income families were less likely to have re-ceived any formal sex education.Comprehensive sex education was marginallyassociated with reduced rates of sexual intercourse,whereas adolescents who received no sex educationreported a higher incidence of intercourse. The inci-dence of pregnancy was no different in the abstinence-only and no-sex-education groups; only the group thatFemale adolescents said they engagedin sexual activity to avoid the labelof being ‘old fashioned.’AJN0613.Matzo.EvidenceforExcellence.4th.indd 68 5/9/13 2:11 AM
  • 3. ajn@wolterskluwer.com AJN ▼ June 2013 ▼ Vol. 113, No. 6 69received comprehensive sex education had a decreasedlikelihood of pregnancy. Neither sex education pro-gram reduced the incidence of STIs when comparedwith no sex education.4Low income and nonintactfamily structures were found to be predictors for earlyintercourse, pregnancy, and STIs.4Jemmott and colleagues conducted a randomizedcontrolled trial of sixth and seventhgraders to evaluateinterventions to prevent sexual activity.24Participantsin this study received one of four types of instruction:abstinence only, comprehensive sex education, safersex (which encouraged condom use to reduce the riskof pregnancy and STIs), and general health promotion(the control group). The findings suggest that studentsplaced in the abstinence-only group had significantlyless intercourse than those in the control group atthree, six, 12, 18, and 24 months of follow-up (21%versus 29%, respectively; P = 0.02). However, findingswere similar for the comprehensive sex educationgroup compared with the control group (21% versus29%, respectively; P = 0.06), an important pointthat was not widely reported in media coverage ofthis study.The authors acknowledged that the abstinence-onlyinstruction did not meet the criteria needed to qualifyfor abstinence-only federal funding. As explained in aNew York Times article on the study, “Unlike the fed-erally supported abstinence programs now in use,[this program] did not advocate abstinence until mar-riage. The classes also did not portray sex negativelyor suggest that condoms are ineffective, and containedonly medically accurate information.”25Thus, thesefindings cannot be compared with those of most otherabstinence-only research studies.The age of the study participants was another im-portant issue. The mean age was 12.2 (range, 10 to 15years), placing the majority of the subjects in the earlyadolescent stage of development, where they remainedthroughout the two-year study. In this stage, cognitivedevelopment is only beginning and long-term conse-quences of behavior are not yet considered.7The in-terventions were specifically tailored to this cohort.Participants were taught to wait for sex until theywere ready, helped to build skills they needed to say“no,” and instructed in tactics to avoid peer pressure.While appropriate for early adolescents, these sameinterventions may not be appropriate for older teens,who respond to different kinds of instruction.RECOMMENDATIONS FOR BEST PRACTICESNurses can help adolescents and their families byteaching them about sexual development and theprocess for choosing to engage in healthy, age-appropriate sexual behavior. These discussionsshould• incorporate interventions that match the adoles-cent’s level of cognitive development.• describe the effects of peer pressure and com-mon misperceived beliefs.• emphasize the importance of family, friends, andextended family in building relationships andmonitoring adolescent behavior.Cognitive development. Understanding thedevelopmental aspects of behaviors—for example,early adolescents make spur-of-the-moment deci-sions and are limited in their ability to consider theconsequences—can be beneficial for nurses andparents alike. The amount of freedom and respon-sibility given to teens should match their develop-mental level. A 13-year-old, for example, may notknow how to avoid sexual advances or how to con-trol her or his feelings. Impulse control is poorlydeveloped, necessitating adult supervision. Con-versely, 17-year-olds may have experience withfriends of both sexes in supervised social groups.Such experience can increase confidence and cogni-tive skills in potentially sexual situations, ultimatelyenabling older teens to manage their feelings andactions in ways that support their values and be-liefs. Parents can promote healthy group interac-tions by hosting mixed-sex group activities, suchas listening to music or watching movies; activitieslike this can help build the social skills that formthe foundation for decision making in older adoles-cence.Peer groups can encourage or reinforceadolescents’ decisions about whether to engagein sexual activity. Instruct parents to ask their chil-dren how they spend time with their friends andto inquire about their friends’ sexual activities. Insome groups, engaging in sexual activity confershigher status and reinforces a sense of belonging.Adolescents may overestimate their peers’ sexualexploits, which can encourage them to become ac-tive as well.26Parents who are aware of the real andperceived activities of their adolescent’s peers canbe proactive in discussing the risks and benefits ofsexual relationships.Forty-two percent of maleadolescents reported sexualcontact with someone outsideof the dating relationship.AJN0613.Matzo.EvidenceforExcellence.4th.indd 69 5/9/13 2:11 AM
  • 4. 70 AJN ▼ June 2013 ▼ Vol. 113, No. 6 ajnonline.comEVIDENCE FOR EXCELLENCEParental support. When it comes to making de-cisions about sex, teenagers consider their parents’ in-fluence to be more important than that of their peersor popular culture.27In fact, 87% of teens said that“it would be much easier to delay sexual activity andavoid teen pregnancy if they were able to have open,honest conversations about these topics with their par-ents.”27Yet while most parents want to be involvedand welcome dialogue about romantic relationships,5few initiate timely discussions or provide informationthat meets their adolescents’ needs.28Single parentsand those who work long hours may benefit frombuilding support systems of extended family andfriends.Finally, comprehensive sex education can positivelyinfluence decisions about sexual behavior. However,parental supervision remains vital, especially for earlyadolescents who may be unable to adequately con-sider the consequences of their behaviors. Late ado-lescents have the cognitive skill to decide to engagein safe sex if they are armed with information aboutprotection (such as condoms and birth control pills),how to use it, and where it can be obtained. Sexualeducation can result in closer family relationships andimproved adolescent sexual health.RESOURCESCurriculum components for comprehensive sex ed-ucation programs can be obtained from the NationalCampaign to Prevent Teen and Unplanned Pregnancy(www.thenationalcampaign.org) or the Sexuality In-formation and Education Council of the United States(www.siecus.org). ▼Deborah M. Wisnieski is an associate professor and MarianneMatzo is professor and Frances E. and A. Earl Ziegler Chair inPalliative Care Nursing at the University of Oklahoma, OklahomaCity. Matzo also coordinates Evidence for Excellence: mmatzo@ouhsc.edu. Contact author: Deborah M. Wisnieski, deborah-wisnieski@ouhsc.edu. The authors have disclosed no potentialconflicts of interest, financial or otherwise.REFERENCES1. Aspy CB, et al. Youth assets and delayed coitarche across de-velopmental age groups. J Early Adolesc 2010;30(2):277-304.2. Centers for Disease Control and Prevention. CDC fact sheet:incidence, prevalence, and cost of sexually transmitted infec-tions in the United States. Atlanta; 2013.3. Martin JA, et al. Births: final data for 2010. Hyattsville,MD; 2012 Aug 28. National Vital Statistics Reports; http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf.4. Kohler PK, et al. Abstinence-only and comprehensive sex ed-ucation and the initiation of sexual activity and teen pregnancy.J Adolesc Health 2008;42(4):344-51.5. Lagus KA, et al. Parental perspectives on sources of sex infor-mation for young people. J Adolesc Health 2011;49(1):87-9.6. Fonseca H, Greydanus DE. Sexuality in the child, teen, andyoung adult: concepts for the clinician. Prim Care 2007;34(2):275-92; abstract vii.7. Shafii T, Burstein GR. The adolescent sexual health visit.Obstet Gynecol Clin North Am 2009;36(1):99-117.8. Fantasia HC. Adolescent sexual decision-making: a reviewof the literature. J Nurse Pract 2009;13(11/12):22-30.9. Kershaw TS, et al. Misperceived risk among female adoles-cents: social and psychological factors associated with sexualrisk accuracy. Health Psychol 2003;22(5):523-32.10. Chapin J. It won’t happen to me: the role of optimistic biasin African American teens’ risky sexual practices. HowardJournal of Communications 2001;12(1):49-59.11. Zwane IT, et al. Adolescents’ views on decision-making regard-ing risky sexual behaviour. Int Nurs Rev 2004;51(1):15-22.12. Garwick A, et al. Risk and protective factors for sexual risktaking among adolescents involved in Prime Time. J PediatrNurs 2004;19(5):340-50.13. Sieving RE, et al. Maternal expectations, mother-child con-nectedness, and adolescent sexual debut. Arch Pediatr Ado-lesc Med 2000;154(8):809-16.14. Donohew L, et al. Sensation seeking, impulsive decision-making, and risky sex: implications for risk-taking and de-sign of interventions. Pers Individ Dif 2000;28(6):1079-91.15. Manning WD, et al. Hooking up: the relationship contextsof “nonrelational” sex. J Adolesc Res 2006;21(5):459-83.16. Lescano CM, et al. Condom use with “casual” and “main”partners: what’s in a name? J Adolesc Health 2006;39(3):443,e1-e7.17. Lenoir CD, et al. What you don’t know can hurt you: per-ceptions of sex-partner concurrency and partner-reportedbehavior. J Adolesc Health 2006;38(3):179-85.18. Metts S, Fitzpatrick MA. Thinking about safer sex: the riskybusiness of “know your partner” advice. In: Edgar T, et al.,editors. AIDS: a communication perspective. Hillsdale, NJ:Lawrence Erlbaum Associates; 1992. p. 1-19.19. Niccolai LM, et al. New sex partner acquisition and sexu-ally transmitted disease risk among adolescent females. J Ad-olesc Health 2004;34(3):216-23.20. Bennett SE, Assefi NP. School-based teenage pregnancy pre-vention programs: a systematic review of randomized con-trolled trials. J Adolesc Health 2005;36(1):72-81.21. Lindberg LD, Maddow-Zimet I. Consequences of sex edu-cation on teen and young adult sexual behaviors and out-comes. J Adolesc Health 2012;51(4):332-8.22. Underhill K, et al. Abstinence-only programs for HIV infec-tion prevention in high-income countries. Cochrane Data-base Syst Rev 2007(4):CD005421.23. SIECUS: Sexuality Information and Education Council ofthe United States. A history of federal funding for absti-nence-only-until-marriage programs. New York; 2011 Oct19. http://www.siecus.org/index.cfm?fuseaction=page.viewPage&pageID=1340&nodeID=1.24. Jemmott JB, 3rd, et al. Efficacy of a theory-based abstinence-only intervention over 24 months: a randomized controlledtrial with young adolescents. Arch Pediatr Adolesc Med2010;164(2):152-9.25. Lewin T. Quick response to study of abstinence education.New York Times 2010 Feb 2. http://www.nytimes.com/2010/02/03/education/03abstinence.html.26. Baumgartner SE, et al. Assessing causality in the relationshipbetween adolescents’ risky sexual online behavior and theirperceptions of this behavior. J Youth Adolesc 2010;39(10):1226-39.27. Albert B. With one voice: America’s adults and teens soundoff about teen pregnancy. Washington, DC: The NationalCampaign to Prevent Teen and Unplanned Pregnancy; 2012Aug. http://www.thenationalcampaign.org/resources/pdf/pubs/WOV_2012.pdf.28. Beckett MK, et al. Timing of parent and child communica-tion about sexuality relative to children’s sexual behaviors.Pediatrics 2010;125(1):34-42.Keywords: abstinence, adolescents, sex educa-tion, sexual behavior, sexual health, sexuality,sexually transmitted infectionsAJN0613.Matzo.EvidenceforExcellence.4th.indd 70 5/9/13 2:11 AM